Tuesday, July 25, 2006

Skin Cancer

Dear Lisa,

My mother told me that children are now developing skin cancer at a young age. Is this true? Are children getting skin cancer? I thought that you got skin cancer when you were older, after years of being exposed to the sun. "What can I do to prevent my son from getting skin cancer?

“Skin cancer in children?”

Dear “Skin cancer in children?”,

You are right, the risk of developing skin cancer does increase with age. According to the 2005 Strouse article from the Journal of Clinical Oncology, the chance of developing Melanoma increases 2.9% per year of life. (1) Therefore, as a person gets older, they develop a greater chance of developing skin cancer. Even though, skin cancer is typically found in the older population, there has been recent documentation in the literature that pediatric skin cancer is on the rise. In the past two decades, pediatric Melanoma cases have increased by more than 100%, according to the Skin Cancer Foundation. (2) So, your mother is right too!

Since skin cancer has always been considered an adult disease, the index of suspicion of skin cancer in the pediatric population is very low. Because of this many Pediatricians do not diagnose skin cancer until it is in the later stages. (3) A retrospective study suggested that part of the reason for the late diagnosis of pediatric skin cancer is because the disease may present differently and the symptoms may appear differently in the young as compared to adults. Interestingly the researchers found that the typical signs of skin cancer that you see in adults are not necessarily the same signs to look for in children.

Most patients and clinicians follow the ABCD rule to determine if a lesion is suspicious for cancer. It turns out that the ABCD rule didn’t always prove helpful in the pediatric population. The ABCD rule outlines typical expectations of a cancerous lesion with each letter representing a typical finding. “A” stands for asymmetry which means cancerous lesions have an uneven shape. “ B” represents border irregularity. “C” stands for change in color of the lesion. “D” represents the diameter or size of the lesion. If the size of the lesion is large, or greater than 6mm it may be suspicious for cancer. This pneumonic guideline is helpful for the adult population, but may not necessarily be a good rule of thumb for children. (4) It was found that Melanomas can start as a speck and do not necessarily have to be the size of an eraser. (3)

In reviewing past cases of pediatric skin cancer, researchers found that of the 33 patients studied; only 14 lesions were asymmetrical. The majority of the lesions did not have an irregular border and actually 29 of the patients had cancerous lesions that had well defined borders. They also found that 14 of the lesions were not brown or black in color. They did find that pediatric lesions tended to be thicker and have nodular features. This study reported that the site of origin in 15 of the 33 children was on the extremities. Ten were found on the trunk, and eight on the face and head. (4) Another important thing to note is that only 20-40% of Melanomas originate from a pre-existing lesions. (5) Therefore the common notion that skin cancer only “develops” over time from an already known lesion is not always true. More than half of the skin cancer lesions diagnosed are not from a pre-existing lesion.

Children who are risk for developing Melanoma include those of white race, with fair skin, blond/red hair, light eyes, freckles, a history of sunburn, a family history of Melanoma, DNA disorders and those with compromised immune systems. (5) Other risk factors include use of indoor tanning booths, history of blistering sunburns and excessive sun exposure. (2,6,7).

The purpose of this information is not to scare you or encourage you to rush to the Pediatrician’s office to get your child checked for skin cancer. Its purpose is to increase your awareness about the possibility that children can get skin cancer too. This information can only help our children by encouraging their parents to be diligent about skin protection and in tuned to any new lesions on their child. Since Melanoma has a 90% cure rate if detected early, measures to prevent and diagnose skin cancer early is the key. (7)

My advice is to watch for the development any new or different looking lesions and bring them to your pediatrician’s attention. If your child has risk factors it is a good idea to have a total body skin evaluation on a regular basis. Your child’s Doctor or Nurse Practitioner can do this at her yearly physical examination. Some children with multiple moles and lesions may see a Dermatologist on a regular basis in order to have a total body skin evaluation. Research by Fisher in 2005 showed that the chances of finding a Melanoma are increased six times by conducting skin cancer screening through total body skin examinations. (8) This type of examination views the entire surface of the body and is critical for detecting melanoma since as much as 80% of melanomas are found on the body area covered by clothes. (7,9).

Lastly, the best prevention is using sun protection. Applying sunscreen every 2 hours while your child is out in the sun and remembering to reapply after swimming is a good idea. This is particularly important in the pediatric population because half of a person’s total sun exposure occurs before age 18. Despite the well known and documented statistics linking sun exposure to skin cancer, still less than 33% of adults, adolescents and children routinely use sun protection according to the Skin Cancer Foundation.(2) Since 90% of all skin cancers are due to sun exposure the simple task of applying sunscreen is your best line of defense.

(1)Strouse J, Fears T. Pediatric melanoma: risk factors and survival analysis of the surveillance, epidemiology and end results database. J Clin Oncol. 2005:23:4735-4741.
(2) Grassia T. The earlier, the better for skin cancer prevention. Infectious Diseases in Children. 2006;May:56.
(3)Johr R. Literature review on pigmented lesions. Presented at: Masters of Pediatrics 2006 Leadership Conference: Jan. 25-30, 2006: Bal Harbour,Fla.
(4)Ferrari A, Bono A. Does melanoma behave differently in younger children than in adults? A retrospective study of 33 cases of childhood melanoma from a single institution. Pediatrics. 2005; 115:649-654.
(5) Richards C. Pediatric melanoma rates increasing. Infectious Diseases in Children. 2006; May:54.
(6) Richards C. Risk of developing melanoma increases with age. Infectious Diseases in Children. 2006;May:55.
(7) Tuchman M, Weinberg J. Why everyone’s skin needs to be examined. The Clinical Advisor. 2006;Feb33-38.
(8) Fisher N, Schaffer J, Berwik M. Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma. J Am Acad Dermatol. 2005:53:393-406.
(9) Richards C. Total body skin exams help save pediatric lives. Infectious Disease in Children. May; 2006.55.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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